Mrs X is an 84 year old British lady. She has type 2 diabetes, hypotension and she is also MRSA positive. She was admitted to her local hospital where she was diagnosed with acute coronary syndrome and pulmonary oedema, but has now been transferred from her local hospital to this current care setting because of this diagnosis. After admission patient Mrs X had an angiogram, via right femoral approach, which has shown multi vessel disease (LMS, LAD, LCX and RCA). She had a failed angiogram via right radial approach. Mrs X has also had an Intra-aortic balloon pump inserted via right femoral approach. On arrival to the ward significant, vital observations were taken, these were blood pressure, O2 saturation, respiration rate and heart rate, her blood glucose level was also measured as she was diabetic. An admission ECG test was also done. This patient has been chosen for the case study as a very effective care plan has been written for her needs while she is in hospital, also the care that Mrs X needs and the problems she is facing is very common for other patients on this ward, therefore it will help develop understanding for other patients as well as her and will also help build on further knowledge for the future. A very informative care plan has been developed for Mrs X by looking after from when she was admitted to the ward and seeing and reading about the problems she has. The involvement in her care has also helped nurses build a therapeutic relationship with her.
The nursing model that will be using is the Roper, Logan and Tierney model of nursing. The Roper, Logan, Tierney model (1996) centres on the patient as an individual and his relationship with the five components of the model. The five components are activities of living, lifespan, dependence/independence, factors influencing the activities of living and individuality in living (Holland et al 2008). This model is based on the 12 activities of living and nursing, which are maintaining a safe environment, communication, breathing, eating and drinking, elimination, personal cleansing and dressing, controlling body temperature, mobilising, working and playing, expressing sexuality, sleeping and dying. The activities of living are influenced by biological factors, psychological factors, socio-cultural, environmental and politico-economic factors. The model takes a holistic approach to nursing care and focuses on the patient as a whole and not just their illness.
On admission a patient assessment was carried out on Mrs X she was assessed according to the hospital policy. The framework that was used to carry out this assessment is shown as Appendix 1. This is the nursing assessment framework used at the hospital when each patient is admitted to the ward. When Mrs X was admitted to the ward after having surgery the assessment form was filled out from information retrieved from her case notes and her medical history. She was also personally asked the questions on the form in a planned assessment interview so the assessment could be as accurate as possible; therefore the precise and correct judgement can be made for the care Mrs X needs (Holland et al 2008). The planed assessment interview which took place when Mrs X was admitted to the ward was an opportunity to collect detailed, specific information in order to offer the most effective interventions (Mallet and Dougherty, 2000). This was carried out using a holistic approach and assessing her overall needs, instead of only looking at her medical needs, these include physical, psychological, emotional and social needs. There are many problems to be addressed for X but the three main problems that my care plan will address are:
Maintaining a safe environment
Eating and Drinking
The first problem is maintaining a safe environment. For Mrs X the focus will be on her internal environment rather than external environment. Other problems associated with maintaining a safe environment that...
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